LDP

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H.U.B. Referral Form

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(Housing, Undocumented and Benefits Navigation)

First Name*

Last Name*

Date of Birth*

Student ID Number*

Email Address*

Phone Number*

Current Housing Status

Living with Parents/Guardians

Temporary Housing (Couch-Surfing, Living With Friends or Family)

Shelter/Transitional Housing Program

Motel/Hotel

Unsheltered Location (Car, Bridge, Street, Parking Lot, Etc.)

Check all that apply

Current Financial Status

Employed (Part-Time or Full-Time)

Unemployed

Receiving Financial Assistance from Others (Rent, Bills, Insurance, Etc.)

Currently Receiving Financial Aid

Receiving Grant(s)

Receiving Scholarship(s)

Check all that apply

Current Citizenship Status

U.S. Citizen

Deferred Action for Childhood Arrivals (DACA)

Undocumented

Authorized to Work in the United States

Mixed-Status Family (Families Who Have One or More Undocumented Family Member)

Check all that apply

Current Benefits Receiving

SNAP (Food Stamps/Link, EBT)

TANF (Cash)

SSI (Social Security Insurance)

SSDI (Social Security Disability Insurance)

Housing Authority (Section 8, Low-Income Housing)

Unemployment Benefits (Currently Receiving or Need to Apply)

Check all that apply

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